Healthcare Provider Details

I. General information

NPI: 1255913307
Provider Name (Legal Business Name): JONATHAN TYLER SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 PASTURE RD BLDG 299
FALLON NV
89496-5000
US

IV. Provider business mailing address

4755 PASTURE RD BLDG 299
FALLON NV
89496-5000
US

V. Phone/Fax

Practice location:
  • Phone: 775-426-3128
  • Fax:
Mailing address:
  • Phone: 775-426-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101283882
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101283882
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: